We C. EXCEPTIONS NAPHT recognizes the need for tighter control of the exceptions process. We were profoundly disturbed to learn that in the past exceptions have been granted without audit of costs. The Proposed Rule notes that it is expected "that under the proposal few facilities would be able to qualify for exceptions to their payment rates." We commend the Health Care Financing Administration for including "isolated essential facilities" as one group which would qualify for exceptions. urge that the criteria for this group consider patient needs, including reasonable travel times and the full range of treatment modality options. It is impossible for patients to lead meaningful lives and continue to seek employment if they must spend excessive time travelling to and from treatments. The time demands of treatment are substantial; adding excessive travel time makes dialysis treatments a totally consuming activity rather than a means to continue a meaningful life. There has been a great deal of concern among patients that this proposal intends to close units and send unwilling and/or unsuitable patients home. We know that you recognize that home treatment is NOT suitable for many patients for either medical or environmental reasons. Home hemodialysis requires a suitable partner. Any form of home therapy requires space for supplies. Not every patient has these available. Lower socioeconomic status can be correlated with less home dialysis. Units serving predominately poorer populations, therefore, may not be able to benefit from the composite nature of the rate. The Proposed Rule assumes that all units can send patients home. Units which cannot send a signficant number of patients home must be protected so that the patients they serve are protected. We therefore recommend that the "atypical patient mix" basis for requesting an exception rate SPECIFICALLY include those units which cannot legitimately send a significant number of patients home for either medical, environmental, or economic reasons. D. ONE HUNDRED PERCENT COST REIMBURSEMENT FOR HOME DIALYSIS EQUIPMENT, INSTALLATION, MAINTENANCE, AND REPAIR This provision was intended to increase home dialysis and was not eliminated by the Budget Reconciliation Act of 1981. We question the authority of the Health Care Financing Administration to eliminate it and further believe that it is counterproductive to the goal of increasing home dialysis. Although purchase of equipment may be more expensive initially, we believe that it will save money over time. NAPHT recommends that the 100% cost reimbursement for home dialysis equipment be retained. E. EFFECTIVE DATE Dialysis is usually a thrice-weekly procedure. Patients cannot live without this therapy. Therefore any disruptions in the delivery system are life-threatening. Yet the Proposed Rule recommends implementation on the date of publication of the Final Rule. We consider this an irresponsible proposal. Even if every assumption in the Proposed Rule is true and increased home dialysis, better management, and the exceptions process protect the 46% of hospital-based facilities and 28% of indpendent facilities with current costs above the new rates, this cannot happen instantly. Revising management systems takes time, filing an exception request takes time, developing a home training program takes time, and training patients to go home takes time. Changes must therefore be implemented over time. NAPHT therefore recommends that the effective date of any new reimbursement be some time after publication of the new rate and that any facility with current rates in excess of the new rates be given a phase-in schedule to allow them to adjust to the new lower rates. There should be AT LEAST 30 days after the announcement of the new rates before implementation. For facilities which have current rates substantially above the new rates, we recommend implementation occur in several steps over AT LEAST a 12 month period. For example, if the current rate is $50 above the new rate, an intermediate rate $25 above the new rate should be allowed for the first year after the effective date of the regulations and the final rate should not be effective for AT LEAST one year. Although this proposed rule is limited to the new reimbursement rate, the NAPHT would like to make several additional observations and recommendations. Our concern remains that all patients have access to needed therapy. We also recognize the legitimacy of the government and public's concerns about the high cost of the program. We are NOT seeking to protect the current system when we recommend that the Proposed Rule be withdrawn; we are seeking to protect patients. We do recommend some interim money-saving measures, however. 1. Non-productive expenditures should be eliminated. There is simply no excuse for inappropriate billing such as double billing for physician services, billing for "noshows," etc. Whether such billing occurs as a result of poor management or because of fraud is irrevelant. HCFA should institute better review processes to eliminate these expenditures. Consideration should be given to the use of single or regional intermediaries for better management control. Fraud should be prosecuted. 2. Current high cost facilities should be reviewed. It is unfortunate that exceptions have been so easily granted. Existing exceptions should be immediately reviewed, beginning with the facilities with the highest costs and progressing downward. In this way, adjustment begins with those facilities which are potentially the least efficient. Money can be saved without jeopardizing a large number of patients. The National Association of Patients on Hemodialysis and Transplantation, Inc. is committed to an efficient and effective renal program. We offer our ongoing assistance in the development of a payment methodology which assures that all patients receive high quality care in an efficient and effective manner. We would be happy to provide any additional information needed and urge again that this Proposed Rule be withdrawn and revised so that all patients are protected. Sincerely, John Newmann John Newmann, Ph.D., M.P.H. STATEMENT OF RICHARD M. FREEMAN, M.D., PRESIDENT, NATIONAL KIDNEY FOUNDATION, INC., AND DEPARTMENT OF MEDICINE, UNIVERSITY HOSPITAL, IOWA CITY, IOWA Dr. RICHARD M. FREEMAN. Congressman Rangel, Congressman Pickle, my name is Richard M. Freeman. I am president of the National Kidney Foundation. I represent not only doctors but social workers, dieticians, nurses, lay volunteers, and especially patients. When I attended some oversight hearings in the Senate about 4 weeks ago, we were concerned about these regulations and concerned from two major standpoints. We were particularly concerned about the impact of the regulations on the pediatric community. This is a group of patients who require more than the usual amount of care, and there was great concern that pediatric dialysis units might be under jeopardy. We are still concerned about that, and the subsequent comments later in the day will emphasize that even more. We were also concerned about the rural community, since it appears on the basis of analysis of at least one rural community, Network, No. 8, Inc., which includes Iowa and Nebraska, that although this area accounts for 1.3 percent of the dialysis population, in fact, it would be accounting for 2.3 percent of the dialysis savings. There is concern about these communities because large volumes of patients are not as easily obtained. Acquiring nurses of high standard in rural communities may be difficult, too. You may not realize that some people would prefer to go to New York City than to come to Iowa, but nurses are in this category as well. We have broader concerns since these past 4 weeks because we have had input from many areas. We think the hospital based facilities are in some jeopardy. I think also the independent facili ties are in some jeopardy. The written testimony will essentially speak to these issues in more detail. I would like to make one point, however, related to the intent of these regulations as an incentive for home hemodialysis. We are concerned that that may not be so. Although, according to the regulations, the reimbursement for in-center dialysis would decrease, the reimbursement for home dialysis would actually increase. Since patients are responsible for 20 percent of these costs, their responsibility actually increases, rather than decreases, with the regulations. We suspect that a home dialysis patient now receiving dialysis in the home, will be responsible for about $750 more tomorrow than he would have last year. We think, therefore, that this is not an incentive in the right direction. Furthermore, we believe there are now figures available from some of the data obtained by HCFA through Networks that as many as 40 to 50 percent of new patients entering dialysis each year are being trained for the home. I am talking about new patients, not total population. But if you take the new patients as a denominator and put those trained for home as the numerator, it appears that 40 to 50 percent are now being trained for home. We recognize that peritoneal dialysis is responsible for a lot of this increase. Nonetheless, we have some evidence that home dialysis, which was as low as 11 percent, is now maybe as high as 17 percent. So improvements are being made. We are also concerned that such regulations may indirectly lead to selection of patients for dialysis, and while we realize that this was not the intent of Congress, it greatly concerns us. About 6 weeks ago, I saw a patient in the renal clinic. I read my note on this patient written in 1972, and it said, "This is a 55-year old woman who is not an ideal candidate for dialysis and transplant because of her age and heart disease." It was clear from my note that I thought this woman would never be dialyzed or transplanted. Two months later, I saw my note that said, "Perhaps we can maintain this patient with peritoneal dialysis until Federal funds become available in 1973." Indeed, the Federal funds did become available and the woman has been alive for 10 years. She has never been hospitalized and has clearly benefited from Federal support. I make this comment for two reasons. One, to thank you for the support she has had, she is alive now because of Federal support; and to point out that our ability as physicians to select patients who will benefit is not so great, and we fear being put in that position again. I want to point out that I realize this was never the intent of Congress related to these regulations. Finally, I want to point out that volunteer efforts are underway in many places to try to cut costs, but we must teach each other how to cut costs. Physicians are trained to save lives, not to cut costs. We have got to learn more about how to cut costs. In the State of Iowa, we have been able to buy dialyzers together as a group in order to cut costs. We have changed our billing practices in order to cut costs. We have done a variety of things. We have taken what I call a Cadillac home-dialysis program and made it a Chevrolet program, nonetheless, the patients recognize why we are doing this. They do not complain if it is done properly and if their health is taken into consideration. In summary, I think the regulation should be reworked so that patients are not in any potential jeopardy and the National Kidney Foundation is very anxious to help in any way we can to that end. Thank you. [The prepared statement follows:] |